Often, detailed information on nutrition and chemotherapy is not
easily available. The specific dietary recommendations in this
module show that many drug side effects can be reduced or
controlled. Ideally, the physician, nurse or a registered dietitian
should be working with the oncologist and yourself.

Cancer therapy or the cancer itself may cause changes in your
body chemistry that result in a loss of appetite. Pain, nausea,
vomiting, diarrhea or a sore or dry mouth may make eating difficult
and cause loss of interest in food. It is common to lose your
appetite because of anxiety or depression about your disease. Loss
of appetite is usually followed by an undesirable loss of weight by
taking in an insufficient amount of calories every day.

The reduction of caloric intake can lead to a loss of muscle
mass and strength and other complications by causing:

Interruptions of medical therapy, impeding effective cancer
therapy

Poor tolerance of surgery

Impaired efficacy of chemotherapy and radiotherapy

Decrease in quality of life

Decrease in immunity

A totally different approach to eating is required when you no
longer have an appetite to nourish you. You will need to learn to
eat even when you do not feel like eating and to approach eating as
an important part of your therapy. Talk to a dietitian, nurse or
your doctor about ways to improve your appetite. It is important
for your general sense of well-being and your ability to fight the
diseases that you eat a nutritious diet and try to maintain your
weight.

As appetite may no longer motivate you to eat well, you will now
need a planned approach. You may improve your appetite by
experimenting with different ways of preparing and serving food.
Choose foods high in calories and proteins, so you can get maximum
energy and avoid losing weight (which will cause weakness).

If you don't seem to be making progress, you might ask your
doctor about medications that can stimulate your appetite such as
Megace® or Marinol®, a legally available synthetic form of
THC (the active ingredient in marijuana) in capsule form.
Marinol® is usually used as an antinausea drug, but it also
stimulates the appetite. Some states legally allow marijuana to be
used to reduce nausea symptoms for patients receiving chemotherapy
under the supervision of their physicians.

Tips for reducing loss of appetite are found under "Helpful
Hints for Better Nutrition" in chapter 31, Everyone's Guide to
Cancer Therapy (Dollinger, Rosenbaum, Tempero and Mulvihill),
or Nutrition Problems: Causes and Solutions chapter 27
Supportive Cancer Care (Rosenbaum and Rosenbaum). Also
choose from the high-calorie/high-protein small meal or snack diet
ideas in the accompanying booklet on nutrition.

Abnormalities in taste perception is common, especially for
those who are receiving concomitant radiation therapy to the neck
and mouth area. "Taste blindness," or an altered sense of taste, is
a temporary condition that occurs because of effects on taste buds
that are mostly located in the tongue. Sometimes, only partial
recovery of taste occurs. Common complaints are of food tasting too
sweet or too bitter or of a continuous metallic taste.

A loss of taste perception makes it more difficult to eat, which
leads to weight loss. Taste loss tends to increase in proportion to
the aggressiveness of treatment. With time and healing, the sense
of normal taste often returns.

Often a strong aversion to certain tastes or foods follows an
illness. Since taste aversions may also be associated with
chemotherapy, avoid eating your favorite foods on the day you
receive chemotherapy.

Mouth care can help. Brush your teeth several times a day, and
use mouth rinses, water mixed with salt, and/or daily use of
Hydrogen peroxide flora or baking soda, or diluted
Cepacol® or Chloraseptic®).

Gymnema Sylvestra, a herbal tea that is often used by
professional wine tasters, will deaden the taste buds to sweet
tastes for about 20 minutes. This should be held in the mouth for
about five minutes before eating.

Drinking water, tea, ginger ale or fruit juices mixed with club
soda may remove some of the strange tastes in your mouth. It might
also help to munch on hard candies, such as sugar-free mints of Tic
Tacs®. Sugar-free gum or hard candies often reduce
after-tastes.

Add wine, beer, mayonnaise, sour cream or yogurt to soups and
sauces to disguise the off tastes of other foods.

Eat starchy foods such as bread, potatoes, rice and plain
pasta. Do not add butter, margarine or other fatty substances to
these foods.

Eating in relaxed and pleasant surroundings can help reduce
problems of altered or lack of taste (taste blindness).

You may have cravings for spicy and salty foods. Spicy, highly
seasoned foods are irritating to many people. However, if your
doctor does not advise against such foods, and if you can tolerate
them, by all means satisfy such urges.

Often flavorings such as herbs, spices or food seasonings may
help. Also, acidic foods such as grapefruit may stimulate taste
buds (but avoid them if they irritate your mouth).

Experiment with different food textures such as crunchy,
creamy, crispy foods.

High-protein foods and supplements are particularly important
when taste blindness prevents you from eating properly.

Nausea and vomiting are frequent side effects of cancer therapy.
They can also be brought on by an obstruction in the intestine,
irritation of the gastrointestinal tract (gastritis) or brain
tumors.

Constant vomiting naturally makes it impossible for you to eat
or take fluids, so whatever can be done to reduce nausea should be
done before vomiting starts. Paying attention to psychological
causes and using antinausea drugs and antianxiety and relaxing
medications will help control symptoms. (See for doses of
antinausea drugs). Rinsing with 1/4 teaspoon baking soda, 1/4
teaspoon of salt and 1 quart of water can help by neutralizing
acids in the mouth

Nausea and vomiting may begin one to three hours after treatment
or even as long as two to four days later. You may start to fear
therapy, a fear that can gnaw at you and make you want to avoid
treatment. Nausea and vomiting may also make problems such as pain
control and maintaining an overall good quality of life much harder
to deal with. A wide variety of antinausea drugs are available to
minimize or prevent the problem.

Medications are available to combat nausea and vomiting. These
include Compazine® (prochlorperazine), Ativan®,
Benadryl® (diphenhydramine), Decadron®, Dramamine®,
Inapsine® (droperidol), Reglan® (metoclopramide),
Zofran® (ondansetron) and Kytril® (granisetron).
Marinol® is also effective. The FDA has approved Marinol®,
the active ingredient in marijuana, in a capsule form. Many
patients obtain marijuana from private sources and add it to
brownies, cookies or other food, brew it as tea or take it in
gelatin capsules by mouth or in rectal suppositories (see
below).

Chemotherapy often causes nausea and vomiting. However, it is
estimated that up to half of all people receiving chemotherapy
experience some nausea or vomiting before treatment. This is known
as anticipatory nausea and vomiting (ANV) and usually makes the
nausea and vomiting even more severe when the chemotherapy is
actually given. ANV can become such a set psychological pattern
that the amount of chemotherapy that can be given must be reduced.
And once the psychological pattern of ANV is established, it is
much harder to control nausea and vomiting before and after
treatment. (This behavior pattern was described 90 years ago by the
Russian physiologist Pavlov and is referred to today as Pavlov's
syndrome.)

The aim in chemotherapy is to deliver a therapeutic amount of
drugs with the least side effects. But each chemotherapy agent and
each drug combination has a potential for causing nausea and
vomiting. Getting three or four drugs at a time, which is often the
case, can make the reaction even more severe. The dosage and the
number of cycles to be given also contribute to the reaction.

You, your family and even your friends should talk with your
doctor about the type of chemotherapy you will be getting. For each
drug or drug combination, a program should be established that
allows you some control over the situation. With psychological
factors playing such a big part, it is very important that you be a
participant in preventing nausea and vomiting.

Your anxiety state, how you feel about yourself and your cancer
and how you respond to stress and disease, are all important
factors in setting up this psychological pattern. And once the
pattern is established, all kinds of stimuli can trigger feelings
of nausea: the colors or smells in the room where the chemotherapy
is given, the smell of rubbing alcohol used to prepare you for the
IV needle, the sight of the nurse entering the room or even the
sight of the hospital.

To deal with this problem, you will have to take steps both to
relax before your chemotherapy and to not inadvertently set up
situations that become associated with nausea. Some patients
benefit from meditation, psychological support and aversion
training (through media such as audiotapes to help prevent fear and
nausea). Here are some other suggestions.

Try to relax in a quiet, darkened room before your treatment
sessions.

Use behavioral techniques to help you relax and control any
triggering stimuli: hypnosis, relaxation therapy, imagery or
listening to a tape of your favorite music or a relaxation
tape.

Perhaps try acupuncture or acupressure, which have been
effective in controlling nausea and vomiting in some cases.

Try seasickness wristbands available at any drugstore. The
pressure point is 3 fingers down from the crease of your wrist, in
between the tendons.

The time of day when you get treatment can sometimes make a
difference. If you usually get nauseated in either the morning or
the afternoon, try to change your appointment schedule.

Avoid eating hot, spicy foods or other dishes that might upset
your stomach or gastrointestinal tract. Replace fluids and
electrolytes. Drink extra fluids before a chemotherapy treatment to
help your body get rid of chemotherapy byproducts.

Avoid eating for at least two hours before your treatment. Eat
foods that are easily digested (high-carbohydrate, low-fat). Take a
snack with you to treatment. If you experience "dry heaves," you
may be able to get relief by eating something light, such as
crackers or dry toast, before your therapy. Pregnancy anti-nausea
programs can provide helpful suggestions.

Popsicles, salty foods, soda crackers and toast are often well
tolerated. Avoid overly sweet, greasy, hot or spicy foods and foods
with strong aromas, as they often aggravate nausea. Food served
chilled or at room temperature may be more appealing.

Avoid cooking odors that may bring on nausea by having friends
or family prepare your meals at their own homes and bring them over
to you, or order in from a restaurant. To reduce the smell of
beverages, drink them through a straw.

Always avoid your favorite foods when you are
getting chemotherapy. You might start to associate these foods with
treatment, nausea and vomiting and develop a strong aversion to
them.

Two areas in the brain have been identified as being responsible
for nausea and vomiting, and certain drugs and other methods can
selectively block these areas. Your doctor can work out a program
to combat your nausea, although if one drug or drug combination
doesn't work as well as you would both like, you may have to
experiment with various programs. Generally, antivomiting drugs
(antiemetics) should be taken 30 minutes before chemotherapy so
they have time to take effect.

If vomiting has already started and you cannot keep a pill
down, antinausea suppositories such as Compazine® or Tigan®
may help.

Long-acting capsules such as Compazine® Spansules can be
very helpful, since they work for 6 to 12 hours.

Ativan® (lorazepam) and Decadron® (dexamethasone), both
sedatives, may help block the brain's vomiting center. This is also
a powerful combination for blocking anticipatory nausea and
vomiting. Ativan® can be taken under the tongue for rapid
absorption during severe nausea. Xanax® (alprazolam), another
sedative, or other anti-depressants, may also help to reduce
anxiety. Ativan® is an antidepressant, antianxiety and sleeping
tablet that can cause amnesia, which might take the edge off any
memory of vomiting once the episode is over.

Some forms of marijuana-the natural tetrahydrocannabinol (THC)
and the synthetic Marinol®-may control nausea and vomiting.
However, they can also cause drowsiness, dry mouth, dizziness, a
rapid heartbeat and sweating. The use of marijuana to alleviate
cancer therapy side effects is legal in some states.

Granisetron (Kytril®), ondansetron (Zofran®) and
dolasetron mesylate (Anzemet®) are the most significant new
drugs used to control nausea and vomiting caused by intensive
chemotherapy and radiotherapy. They may be needed with chemotherapy
drugs or when you cannot get relief with other antinausea agents.
They are often given with Decadron ® IV. They suppress vomiting
in 60 to 80 percent of patients and are even more effective in
combination with other antinausea drugs. Anzemet® and
Kytril® last longer, often for one day.

Several antiemetics are available by prescription for use at
home in the event that nausea or vomiting are persistent.

Drug Name

Usual Dose

Side Effects

Cost

Prochloperazine
(Compazine®)

10 mg Every 8 hours

Sleepiness, dystonic reactions, lockjaw

$0.20/tablet

Lorazepam .5-1mg
(Ativan®)

Orally every 4-6 hours as needed 4 to 8 mg

Sleepiness, confusion

$0.50/tablet

Dolasetron 100mg
(Anzemet®)

Orally one daily

Headache, constipation

$$

Ondansetron 4-8mg
(Zofran®)

Orally 2 to 3 or tablets daily

Constipation

$15.00/8 mg

Granisetron 1mg
(Kytril®)

Orally twice a day 2 mg daily

Headache

$35.00/1mg

Marinol® 5mg

Daily 3-4 times or daily as needed

Stimulation, confusion

$14.00/tablet

Megestrol 800mg

Orally divided dose (16 Oz. suspension )

Fluid retention, edema

$ 300.00/pint

Megace® 40 mg daily

Orally four times

Edema, impotence

$8.99/tablet

Dexamethasone 2 mg
Decadron®

4-8mg Orally twice daily with meals

Insomnia, stomach

$0.50/tablet

Metoclopramide 10mg
(Reglan®)

One to two orally four times daily

Diarrhea, anxiety, sleepiness

$0.60/tablet

Delayed nausea and vomiting can occur after cisplatin,
carboplatin, and cyclophosphamide chemotherapy. The most effective
antinausea medications for delayed nausea and vomiting are
Reglan® and dexamethasone. However,these drugs have more side
effects than the "setrons" (ondansetron,granisetron, and
dolasetron). A setron should be used after Reglan® and
dexamethasone has been tried. If effective a setron may be used as
a preventive therapy during the next cycle of chemotherapy.

A sore or ulcerated mouth or throat is a frequent side effect of
chemotherapy. This condition may clear up in a few days, unless
your recovery is slowed by malnutrition If symptoms persist,
consult your physician; you may have a viral or fungal
infection.

The mouth and digestive tract are composed of cells (mucosa)
that are more sensitive to chemotherapy. The lining, or mucosa, of
the gastrointestinal tract, which includes the inside of the mouth
and throat, is one of the most sensitive areas of the body. Thus,
during or after chemotherapy, a cancer patient may present with
mouth problems, ranging from dryness to ulcers. Many chemotherapy
drugs can inflame the lining, a condition called mucositis.
Mucositis appears as redness (inflammation), sores (ulcerations)
and associated discomfort and pain.

These mouth problems are most often due to chemotherapy but can
be caused by other medication. Three to ten days following
chemotherapy, patients may experience a burning sensation, followed
by ulcers. When ulceration develops, treatment is mostly supportive
until the cells regenerate themselves, which takes about 7 to 14
days (most commonly associated with a low white blood cell count).
This can impact on oral comfort and nutrition, but adequate care
can minimize these effects. Since these changes (mucositis) are
primarily inflammatory, corticosteroid treatment is often
helpful.

When using cytotoxic chemotherapeutic drugs, it is extremely
important to keep patients free from the oral foci of infection and
pain to minimize local infection and bacteremia, and to enable them
to maintain a nutritious diet. The chemotherapeutic agents utilized
to eradicate tumor production also adversely affect normal cells,
particularly those that have relatively high turnover rates, such
as oral epithelial tissues. The depressant effect of therapy on
oral epithelial mitoses can result in thinning and ulceration of
the tissues as well as salivary glands and taste dysfunctions. The
oral ulcerations may be due to direct cellular cytotoxicity from
the chemotherapeutic agents, increased susceptibility to
microorganisms owing to neutropenia (bone marrow suppression),
trauma, or a combination of these factors.

A good oral hygiene program includes dental cleaning and
scaling, followed by daily brushing and careful flossing to reduce
plaque.

Any scaling, cleaning, tooth extractions or repair of cavities
should be done before cancer therapy begins. Extractions especially
should be completed at least two weeks before therapy to give your
mouth a chance to heal. Ill-fitting dentures should be adjusted or
replaced. Any periodontal or dental work has to be coordinated with
your oncologist.

Before any dental work is to be performed, your blood counts
should be checked to be sure that your body can take care of any
infection or bleeding (low white cell counts can lead to
infections, and a low platelet count may lead to bleeding).
Antibiotics are recommended if your white blood cell count is low
or there is an infection. Unless there is an emergency, dental
procedures should be delayed till the blood counts return to a
normal range.

Patients should brush their teeth 3 to 4 times a day with a soft
toothbrush or sponge and use floss with care so as not to cut or
injure the gums.

Patients should rinse their mouths frequently with salt water,
baking soda or chlorhexidine (Peridex® or Periogard®)
following chemotherapy. The use of floss, electric toothbrushes and
Waterpic® appliances should be curtailed if the gums are
swollen, sore or tend to bleed.

Xylocaine® is a local anesthetic available as a 2% gel used
topically to decrease pain, but has a short duration of action.
Over-the-counter (OTC) Orabase B® may also be of some help.
Protective agents such as SucralfateTM or
Kaopectate® are also used to cover ulcers and decrease
irritation. Irritant substances like hydrogen peroxide may worsen
the ulcers. Topical steroids should be used with caution as they
may facilitate fungal infections. In addition, patients should
avoid foods that cause irritation. Preference should be put on soft
moist foods.

The following daily steps will help your mouth stay in good
shape:

Use a soft-bristle toothbrush and soften it more by soaking it
in warm water. You may find that brushing with a paste of baking
soda and water is less irritating than commercial toothpaste.
Biotene toothpaste (OTC) is also non-irritating and contains
natural salivary enzymes that help control bacteria.

If brushing your teeth is painful, use either a cotton swab or
Toothetes, a sponge-tip stick impregnated with a dentifrice
(toothpaste). A Q-tip dipped in 3% hydrogen peroxide followed by a
warm water rinse may help remove debris from around the teeth.

Avoid commercial mouthwashes. Some of these have ingredients
(especially alcohol) that can irritate your mouth even more. Lemon
glycerin swabs may make your mouth feel clean but they are not
recommended because glycerin can dehydrate and will make your mouth
drier.

A Water-Pik® to cleanse your mouth is helpful but must be
used with caution, since the pressure of the waterjet may irritate
tissue.

Undiluted clorhexidine mouth rinses (Peridex ®,
Periogard®) may help gum inflammation and bleeding, but
contain alcohol and may sting. Dilution of these rinses defeats
the antibacterial advantages.

In chemotherapy, the mucositis is usually due to the low white
blood cell count; in radiation to the head and neck, it is usually
due to the necrotic and inflammatory effect of radiation energy on
oral mucosa.

If the soreness in your mouth becomes severe, there are quite a
few anesthetic agents you can use on a short-term basis. If your
symptoms persist, you should have a complete mouth evaluation.
There is an increased risk of mucositis for those who smoke.

Benadry® elixir, lozenges and analgesics may help reduce
mouth pain.

Swishing and gargling the anesthetic gel viscous Xylocaine®
2% can help you eat if you have pain in your mouth, pharynx or
esophagus. Use 1 tsp.(5 mL) viscous Xylocaine® before meals
(Hold in mouth for one minute, then spit out).

Cepacol® Lozenge, Chloraseptic spray and lozenges or the
use of tea for swishing and gargling may be of some help.

Frequent use of a gentle mouthwash may help reduce discomfort
or pain. A solution of 1 tsp. baking soda and salt dissolved in
warm water may be used instead of commercial mouthwashes, which may
be irritating to the oral mucosa.

Oral Balance® is a dental gel that moistens the mouth while
sores are healing and also has enzymes that help control oral
bacteria. You may have to apply it often during the day. It can be
obtained over the counter.

Mouth infections can be dangerous. Examine your mouth every day
for any irritation or abnormal appearances or feelings. Report any
changes to your doctor. If you do get an infection, it should be
treated promptly. Sometimes the diagnosis can be made by clinical
characteristics, but may require a smear or cultures.

If you have a herpes virus/infection-acute or recurrent-your
doctor may prescribe oral Acyclovir® tablets. Treatment is also
supportive: bland mouth rinses, analgesics, liquids to avoid
dehydration, and calories to minimize weight loss and
susceptibility to other infections and/or debilitation.